Heart Failure Risk Scale and Atrial Fibrillation

This week we had the pleasure of welcoming a guest speaker for grand rounds, prominent EM researcher and well-known clinical decision rule/tool expert from Ottawa, Dr. Ian Stiell. The focus of his talk was on the Canadian Heart Failure Risk Scale and atrial fibrillation, with some personal travel blogging and joking scattered throughout. Beginning with its derivation and subsequent validation, Dr. Stiell provided a background to the current phase of study that Queen’s will be a part of, the revision and validation of the Canadian Heart Failure Risk Scale. Approximately 1 million people are seen in the ED annually in Canada for acute heart failure, 40-60% of which are admitted to the hospital.  The Heart Failure Risk Score hopes to provide guidance and standardize practice for ED physicians across the country with respect to admission decisions in this population.  The group had a rich discussion about factors included, surprises found in the literature, and predicted utility of the tool. Dr. Stiell pointed out that in order to find out whether this tool will change practice, an implementation trial would have to ensue – stay tuned! In the meantime, check out the score and look for the bright yellow forms to fill out on your next shift in the ED!

The Canadian Heart Failure Risk Scale

Dr. Stiell finished his talk with a review of his work on management of acute atrial fibrillation and flutter. Refer to the updated Canadian CV Society Guidelines for the latest (see algorithm below). Dr. Stiell is now working with CAEP to adapt these guidelines to the ED – stay tuned!

BONUS feature: Dr. Stiell sold us on two new phone applications to check out – The Ottawa Rules Application and Thrombosis.

Thanks for coming Dr. Stiell (@EMO_Daddy)!

 

 

Mass Gatherings and ED Ultrasound

On February 2 we had the pleasure of welcoming back Dr. Colin Bell, a recent FRCP EM grad, all the way from Denver for a talk on ED Ultrasound and hearing some more stories from Dr. Terry O’Brien.

The legendary TOB started the morning off with a talk on mass gatherings, using the last Tragically Hip concert as an example. He took us through the planning, equipment, personnel involved, and lessons learned on the day. Our crew of one nurse (thanks Patti!), multiple residents, staff physicians, and essential administrative assistants provided excellent care and diverted 35 people away from the crowded hospital. EMS was instrumental in the success of the event as well. Kingston’s population received an additional 25, 000 that day!

Here are some resources on mass gatherings to take a look at in preparation for the next big event:

Colin Bell then took us through ‘The Second Phase of POCUS’, illustrating the growing utility of ED ultrasound with a few key cases in which management was altered based on bedside images. It is an exciting time for POCUS and is becoming more of an essential adjunct to diagnostic workups in the ED, especially when time is of utmost importance.

Don’t be shy to ask Colin about the cool new initiatives he is taking part in across the border – he also has some interesting stories to tell practicing EM in an entirely different context than we see here in Kingston.

Here is a reminder of a previous post in which we included a number of valuable online resources for ED ultrasound.

 

Thyroid Emergencies and CBME EPAs

On January 25th Dr. Andrew Hall gave us a reminder the concept of CBME and what it will look like next year. Dr. Heidi Wells followed with an excellent overview of Thyroid disorders encountered in the ED.

Andrew re-iterated the model of CBME and how it will fit into our emergency medicine program starting July 2017. He provided a list of the current entrustable professional activities (EPAs) for emergency medicine and a rich discussion ensued. Overall, it is an exciting time in medical education and Andrew convinced me that our already great program will only get better with this shift towards an outcomes-based, learner centered model! Feel free to ask Dr. Hall all about it, or refer to the PGME website for more information.

Heidi then took us through an approach to thyroid disorders in the ED – with tons of clinical pearls and important take home points to use on your next shift. See the infographic below for a summary of the key messages, and click here for a downloadable pdf version:

Interestingly, Queen’s wasn’t the only institution focused on thyroid disorders that week – the twittersphere was lighting it up!

In true FOAMed spirit, check these resources from the Bold City EM program in Jacksonville, Florida on endocrine, metabolic and nutrition themed topics. Thanks Bold City EM!

 

Exploring the Spectrum of Burnout to Wellness

Just in time for #CAEPWellness2017 Mikayla presented at Grand Rounds on the topic of Burnout to Wellness.She presented a great deal of literature on the topic and made a convincing case for finding ways to help each other thrive.

My favourite part of the presentation was when she displayed word clouds made from our group’s responses to a quick survey she had sent ahead of time. The words below represent how our group manifests burnout.

Better yet was her forward-looking, optimistic look at how we might thrive! Mikayla highlighted some things our department already does and pointed to a couple of other institutions and online discussions on the topic including the ALiEM Journal Club “Thriving, Not surviving, in Residency“. This word cloud displays the strategies that our group uses to get and stay well.

At the end of the day as institutions, friends, colleagues, peers, and individuals we have the ability to support each other in being the best version of ourselves possible. At QEmerg we will continue to find ways, big and small, to navigate the spectrum of burnout to thriving.

Check out information about International Emergency Medicine Wellness Week with lots of available resources and important discussions here. Please add your favourite wellness hacks below!

Grand Rounds: don’t RUSH ortho

In this week’s edition of Grand Rounds Zack performed a quick review of the RUSH exam for undifferentiated shock and Theresa outlined some easy to miss orthopaedic injuries. Below are a few resources on both below! 

The RUSH Exam

In the patient with undifferentiated shock you can use the power of the ultrasound to evaluate the “Pump, Tank and Pipes” or the HI-MAP. See the EMCrit post from the original creators.

rush-exam

For a super primer on the RUSH/HI-MAP exam check out this video from 5 minute soon here or this post from ALiEM.

Happy scanning with our new high frequency probe!!!

Easy to Miss Ortho Injuries

There is far too much to cover from Theresa’s awesome review on this topic. I’ve decided to highlight a couple of the injuries that she mentioned with links to the resources about those injuries for some quick reading.

There is a spectrum of scapholunate injuries that are easy to miss. These range from scapholunate dissociation (widening of the scapholunate joint) to peri-lunate dislocation to lunate dislocation.

The posterior shoulder dislocation can be easy to miss. Keep your eye for the lightbulb sign. Maybe we can consider using ultrasound for catching the diagnosis?

The lateral elbow x-ray is your friend. Keep your eye out for signs of occult fracture in this view.

I really appreciated Theresa’s discussion of the Ottawa Ankle rule. She reminded us that these rules can help assess the need for imaging but the components do not make up a complete or thorough ankle exam. Remember to check the proximal fibular head and examine the whole ankle and foot.

Theresa’s 10 Commandments for Ortho Injuries

  1. Know what you are looking for
  2. Obtain proper, perpendicular views, multiple views and specific views
  3. Be aware of specific, occult and dislocation radiographic signs
  4. Know what “normal looks like”
  5. Avoid being distracted
  6. Develop a systematic approach to xrays
  7. Use cognitive forcing strategies – (i.e. always document snuffbox tenderness and DRUJ findings in wrist exams)
  8. ALWAYS obtain post reduction films
  9. Examine the joint above and below
  10. History and physical trump ALL. Examine, image, re-examine.

 

 

Grand Rounds: Stop the Bleeding!!!

Our awesome Stu Douglas did a fantastic job of bringing together the evidence, the lack of evidence, and evidence of the future together into a practical rounds on reversal strategies for anticoagulation and anti-platelet agents.

Consider using the StuDoug Approach (TM) when you see a patient who just won’t stop bleeding.

stop-the-bleeding-png

Download a copy of this click here!

If you are an emergency medicine, elective resident, medical student or otherwise rotating through our program in Kingston and would like to contribute to QEmerg.org please get in touch with Eve or Kristin at (epurdy at qmed.ca)!

Journal club: Updates in Management of Ischemic Stroke and ATACH-2

Dr. Howes opened up his lovely home to host journal club this month on October 5, 2016 – it was an evening of pizza, ice cream, and enlightening discussion. As usual, two articles were featured. The commentary below, written by Kristen, was staff reviewed by Dan.

Endovascular thrombectomy after large vessel ischaemic stroke: a meta-analysis of individual patient data from five randomized trails 

by Goyal et al. published in the Lancet 2016.

Dr. Keegan Selby presented the resident chosen article listed above, providing an excellent summary of the “biggest thing to ever happen to neurology” in the context of current practices. To quote Dr. Rob Brison directly, the authors used a “really cool” technique to combine raw patient data from five previous studies, MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, and EXTEND IA trials. It is amazing to see the possibilities with research collaboration such as this! We were lucky to have a strong staff presence to help us understand the basics of the mixed methods modelling used. The study is not a traditional meta-analysis and avoids much of the bias because patient level data was used and combined, rather than data that had already been sorted through and grouped. Importantly, authors did account for between-trial variation and were able to provide a more powerful and reliable conclusion than each individual study alone with these statistical techniques. Interestingly, the National Institute of Research is hoping to make all raw data available online from authors who publish under their grants in the future. Just think of the possibilities!

evt

In the end, we agree with the authors’ conclusion – EVT seems like a great idea to reduce disability in patients with large vessel anterior circulation ischemic strokes if you live close enough to a center proficient in this technique in a system that can afford it. Here in Kingston, we are capable – what remains to be determined is whether this is something that is feasible and ethical for KGH.

[Extra tidbit: 5 patients have undergone EVT at KGH – it is currently available during business hours to the optimal candidates. Bottom line: discuss with the stroke team if you encounter a patient with a large anterior ischemic stroke in the ED.]

 

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage (ATACH-2) 

by Qureshi et al. published in NEJM 2016

Dr. Howes led the dialogue through the chosen staff article, ATACH-2 . The authors conducted a randomized, multicenter, open-label trial to examine the effects of intensive blood pressure control in acute cerebral hemorrhage, comparing a target of 110-140mmHg to 140-179mmHg using IV nicardipine – and stopped enrollment early due to futility after interim analysis. I won’t go into all of the details but we had rich discussion surrounding the standard treatment of acute cerebral hemorrhage at KGH, the generalizability of the data to our population, the generous enrollment criteria, the inadequate power of the study (keeping in mind it was stopped early), and the practical difficulty and reader uncertainty surrounding specifics of blood pressure control in this study. In the end, as the authors conclude, this will not change our current practice in the management of acute cerebral hemorrhage. A few take home points were emphasized that can be applied to any article:

  • Always look at the estimate of treatment effect – the authors used a very optimistic 10% difference in likelihood of death or disability at 3 months between their intervention and standard treatment to calculate the power needed at the outset of this study.
  • A superiority trial ≠ an equivalency trial ≠ an inferiority trial – refer to a previous post by Eve, Arrests and Ankles at Astors, for a refresher
  • Be alert to misleading conclusions – Dan used a personal anecdote of a indexspecial stuffed animal to remind us to avoid the “blue dog” false conclusion in our research and analyses; just because you don’t find blue dog in your search, does not mean that you can conclude for certain that blue dog is not in the house.

 

Grand Rounds: Pediatric Rashes

This week, Dr. Aaron Ruberto (otherwise known as Mr. Trebek), took us through an exciting and informative game of Jeopardy to teach us about Pediatric Rashes. The ultimate winner was Dr. Eve Purdy, but we all ‘won’ a ton of relevant and always difficult trivia regarding common and serious pediatric rashes encountered in the ED. See the infographic below as a reminder of the basics to use as an approach to these skin conditions in practice. If you have specific questions, I’m sure Aaron would be happy to provide his expert opinion.

gr-sept-29

You can download a pdf of the above summary here: Grand Rounds Sept 29.

You can also check out the following resources to practice your pediatric rashes:

Staff Rounds:

Dr. Nici Rocca presented an interesting case for staff rounds before Aaron took to the mic, reminding us to keep necrotizing fasciitis on our differential as one of the time sensitive, high mortality infections not to miss in the ED! She provided a description of a recent case she had in the ED of an older woman who presented with refractory cellulitis, pain out of proportion, and a history of femoral popliteal bypass. She reminded us of the risk factors (diabetes, vascular insufficiency, trauma, etc.), the physical exam (pain out of proportion, induration beyond visible cellulitis, crepitus, erythema, bullae, necrosis ecchymosis), and the importance of rapid referral to a surgeon as definitive treatment. Imaging can be done but should not delay treatment – CT or MRI are best. Piptazo + Vancomycin OR Clindamycin + Ampicillin + Vancomycin are good empiric regimes to start in the ED. Penicillin + Clindamycin can be used if you are sure it is a type 2 monomicrobial infection with streptococcus! In the end the patient above ended up having a graft infection for which she was placed on antibiotics and taken to the OR to remove the infected graft and repeat her bypass.

Journal Club: Sepsis and Syncope

Dr. Stephanie Sibley stepped up to the plate last-minute and saved the day to host our first journal club of the year on September 13! It turned out to be an excellent showing and invigorating discussion (from what I was able to see – unfortunately I missed most of the first article). Dr. Carly Hagel and Dr. Theresa Robertson led the discussion about the new sepsis guidelines, walking us through the latest publication, The third international consensus definitions for sepsis and septic shock (Sepsis-3). The authors used a variety of methods – database interrogation, systematic literature review, and Delphi consensus with expert critical care physicians to create new and improved definitions for sepsis, septic shock, and pathophysiology of the syndrome. The table below outlines their new and improved definitions.slide1SIRs is out and qSOFA is in…but is it useful for us?

The SOFA (sequential organ failure assessment) score is used in the ICU and is proposed by the task force as a means to clinically characterize a septic patient, not as a tool for management. The authors used database interrogation to identify a SOFA score of ≥2 as a predictor of increased mortality in patients with suspected infection. The quick bedside test that has been proposed to trigger rapid recognition and management in the ED is qSOFA…but it has not been validated outside of the ICU. [SIRS is now considered a tool to help clinicians to recognize infection in the first place, but does not represent a dysregulated response to such infection as occurs in sepsis (poor discriminant and concurrent validity).]

qsofa

Carly + Theresa’s conclusion:

The published conclusion states that the updated definitions and clinical criteria should clarify long used descriptors and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing it. This conclusion is not supported by the data they quote. The SOFA is a predictor of mortality and has not been validated outside of the ICU setting. Nor has the qSOFA. Neither will facilitate earlier recognition – rather may be able to predict mortality in ICU patients.

The article chosen outlined the changes, but in order to find the selection criteria used for inclusion/exclusion of the specific databases used to support their work you will have to read the following:

It will be interesting to see where this new guideline goes and what discussion follows in the critical care, emergency, and hospital inpatient communities.

Syncope

The staff article chosen is one that we are all familiar with after filling out those pink sheets in the ED, involving our very own Dr. Marco Sivilotti: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. Dr. Sibley graciously hosted us in her amazing new place, sharing some statistical knowledge to give insight into the derivation process used to come up with this tool. The most important take away here for our practical purposes is that it is a derivation study. Before we put it to clinical use, it’s important to follow the next phase – validation. Once validated, this tool proposes to help the clinician to identify adult patients with syncope who are at risk of a serious adverse event within 30 days of disposition from the ED. Unlike most clinical tools that we are used to using, this one hopes to allow us to risk stratify patients who present with syncope who are considered both high and low risk by our clinical judgment. We had an interesting discussion as a group with the frustrations of syncope and what we thought about each of the factors included in the tool. Unfortunately he wasn’t able to attend, but feel free to probe Marco for more details – as usual he will have a wealth of information and opinions to share! For a users’ guide to clinical decision rules, see this JAMA article.

We eagerly await the next update on the Canadian Syncope Risk Score!

 

Summer Series: the Art of Regional Anesthesia

This is the final summer series post for 2016! We ended the season with a great session on nerve blocks followed by an adventure to the Agnes Etherington Art Centre for a session on art appreciation.

Below is an infographic, created by Andrew Helt, that can act as a quick reminder of the types of nerve blocks that you can use. You can check out Vault Ultrasound or keep Joey’s sheet handy by taking a picture of it and adding it as a favourite on your phone for more in-depth reminders at the point of care.

regional-anesthesia regional-anesthesia

After learning about nerve blocks we headed across campus to Agnes Etherington. If you haven’t had the opportunity to check it out you should go! The curators were setting up new installations while we were there so it is sure to be enjoyable.  In case you are skeptical about this as a component of our academic curriculum, I will direct you to these resources discussing the value of humanities in medical education here, here and here.

The summer series was a great introduction (for some) and return (for others) to the foundations of emergency medicine. We are looking forward to the academic year ahead!